A woman, who was pregnant with her first child, booked
with a lead maternity carer (LMC) midwife when she was 25+3 weeks'
gestation. The midwife documented the woman's height and weight
during her first booking appointment. Although the LMC did not
calculate the woman's BMI she assessed her to be obese but
considered it appropriate for the woman to birth at a primary care
maternity unit run by midwives.

The woman went into spontaneous labour when she was 40+6 weeks'
pregnant and went to the primary care unit. A core midwife took the
woman's blood pressure which she noted to be high.

The LMC arrived at the maternity unit approximately thirty
minutes later and assessed the woman, noting that her cervix was
8cm dilated and rechecked the woman's blood pressure. The patient
then went outside for approximately one hour and thirty minutes.
During this time no monitoring was carried out.

Following the woman's return the LMC performed an artificial
rupture of membranes, noting thin meconium and blood. The fetal
heart rate was intermittently auscultated with a hand held doppler
device and considered to be satisfactory but the midwife did not
carry out any further maternal observations. A repeat vaginal
examination was carried out about one hour later and the LMC noted
that labour had not progressed.

A further vaginal examination was performed an hour later which
again showed no progress of labour. The LMC was considering
transfer to hospital when a decrease in the fetal heart rate was
noted. The LMC consulted with the hospital secondary care team and
the woman was transferred to hospital. An emergency Caesarean
section was performed. However the baby was delivered with no signs
of life. Sadly, resuscitation was unsuccessful.

It was held that by failing to monitor the woman's blood
pressure and pulse appropriately during labour, and failing to
monitor the fetal heart rate for a one and a half hour period, the
LMC did not provide services with reasonable care and skill and
breached Right 4(1).

Adverse comment is made that the presence of thin
meconium-stained liquor, coupled with the slow progress noted,
should have prompted increased fetal heart rate monitoring and
discussion with the woman about the appropriateness of delivering
at the primary care unit. Adverse comment is also made about
some aspects of the LMC's antenatal assessment processes and a lack
of detail in some of her documentation.

It is not the Commissioner's role to make findings of causation
and in this case the breach findings against the midwife should not
be interpreted as having any implication as to the cause of this
baby's death.